Download PDF
J Neurol Surg B Skull Base 2013; 74(02): 061-067
DOI: 10.1055/s-0033-1333620
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience

Jagdeep Singh Virk
1   Department of ENT, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
,
Behrad Elmiyeh
1   Department of ENT, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
,
Hesham A. Saleh
1   Department of ENT, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
› Author Affiliations
Further Information

Publication History

03 August 2012

20 October 2012

Publication Date:
13 February 2013 (online)

    Permissions and Reprints

Abstract

Objective To describe our experience of cerebrospinal fluid (CSF) rhinorrhea management.

Design Retrospective.

Setting Charing Cross Hospital, London, a tertiary referral center.

Participants Fifty-four patients with CSF rhinorrhea managed from 2003 to 2011.

Main outcome measures Surgical technique; Recurrence.

Results Etiologically, 36 were spontaneous and 18 traumatic. Eight patients with spontaneous and two with traumatic leaks had previous failed repairs in other units. Success rates after first and second surgery were 93% and 100%, respectively. Mean follow-up was 21 months. Four patients, all of spontaneous etiology, had recurrences; three of these underwent successful second repair with three layered technique, and the fourth had complete cessation of the leak after gastric bypass surgery and subsequent weight reduction. Adaptation of anatomic three-layered repair since then averted any further failure in the following 7 years. Mean body mass index was 34.0 kg/m2 in spontaneous and 27.8 kg/m2 in traumatic cases (p < 0.05). Fifty percent of spontaneous leaks were from the cribriform plate, 22% sphenoid, 14% ethmoid, and 14% frontal sinus. In the traumatic CSF leak group: 33.3% were from the cribriform plate, 33.3% sphenoid, 22.2% ethmoid, and 11.1% frontal.

Conclusion Endoscopic CSF fistula closure is a safe and effective operation. All sites of leak can be accessed endoscopically. We recommend the use of an anatomic three-layered closure in difficult cases.

Keywords

cerebrospinal fluid - rhinorrhea - endoscopic - skull base - spontaneous leaks

Notes

6th International Congress of the World Federation of Skull Base Societies & 10th European Skull Base Society Congress, Brighton, UK. Wednesday 16 May 2012.


6th Australian Rhinology Society Conference, Coolum, QLD, Australia. Sunday 7 October 2012.


 

  • References

  • 1 Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery 2006; 58 (4) (Suppl. 02) ONS-246-ONS-256 , discussion ONS-256–ONS-257
    PubMedGoogle Scholar
  • 2 Carrau RL, Snyderman CH, Kassam AB. The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 2005; 115: 205-212
    CrossrefPubMedGoogle Scholar
  • 3 Har-El G. What is “spontaneous” cerebrospinal fluid rhinorrhea? Classification of cerebrospinal fluid leaks. Ann Otol Rhinol Laryngol 1999; 108: 323-326
    CrossrefPubMedGoogle Scholar
  • 4 Wang EW, Vandergrift III WA, Schlosser RJ. Spontaneous CSF leaks. Otolaryngol Clin North Am 2011; 44: 845-856, vii
    CrossrefPubMedGoogle Scholar
  • 5 Daudia A, Biswas D, Jones NS. Risk of meningitis with cerebrospinal fluid rhinorrhea. Ann Otol Rhinol Laryngol 2007; 116: 902-905
    CrossrefPubMedGoogle Scholar
  • 6 Sakka L, Coll G, Chazal J. Anatomy and physiology of cerebrospinal fluid. Eur ann otorhinolarnygol head neck dis 2011; 128: 309-316
    PubMedGoogle Scholar
  • 7 Lund VJ. Endoscopic management of cerebrospinal fluid leaks. Am J Rhinol 2002; 16: 17-23
    PubMedGoogle Scholar
  • 8 Benjamin E, Wong DK, Choa D. ‘Moffett's’ solution: a review of the evidence and scientific basis for the topical preparation of the nose. Clin Otolaryngol Allied Sci 2004; 29: 582-587
    PubMedGoogle Scholar
  • 9 Anverali JK, Hassaan AA, Saleh HA. Endoscopic modified Lothrop procedure for repair of lateral frontal sinus cerebrospinal fluid leak. J Laryngol Otol 2009; 123: 145-147
    CrossrefPubMedGoogle Scholar
  • 10 Chatrath P, Saleh HA. Endoscopic repair of cerebrospinal fluid rhinorrhea using bone pate. Laryngoscope 2006; 116: 1050-1053
    PubMedGoogle Scholar
  • 11 Kassam A, Horowitz M, Carrau R , et al. Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study. Neurosurgery 2003; 52: 1102-1105 , discussion 1105
    CrossrefPubMedGoogle Scholar
  • 12 Banks CA, Palmer JN, Chiu AG, O'Malley Jr BW, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg 2009; 140: 826-833
    CrossrefPubMedGoogle Scholar
  • 13 Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience. Laryngoscope 2004; 114: 969-974
    CrossrefPubMedGoogle Scholar
  • 14 Mirza S, Thaper A, McClelland L, Jones NS. Sinonasal cerebrospinal fluid leaks: management of 97 patients over 10 years. Laryngoscope 2005; 115: 1774-1777
    CrossrefPubMedGoogle Scholar
  • 15 Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2012; 147: 196-203
    CrossrefPubMedGoogle Scholar
  • 16 Gilat H, Rappaport Z, Yaniv E. Endoscopic transnasal cerebrospinal fluid leak repair: a 10 year experience. Isr Med Assoc J 2011; 13: 597-600
    PubMedGoogle Scholar
  • 17 Presutti L, Mattioli F, Villari D, Marchioni D, Alicandri-Ciufelli M. Transnasal endoscopic treatment of cerebrospinal fluid leak: 17 years' experience. Acta Otorhinolaryngol Ital 2009; 29: 191-196
    PubMedGoogle Scholar
  • 18 Liao W, Lin SH, Huang HT. [Traumatic nasal cerebrospinal fluid fistula: report of 86 cases]. Di 1 jun yi da xue xue bao = Academic journal of the first medical college of PLA 2003; 23: 629-630
    PubMedGoogle Scholar
  • 19 Seth R, Rajasekaran III K, Luong A, Benninger MS, Batra PS. Spontaneous CSF leaks: factors predictive of additional interventions. Laryngoscope 2010; 120: 2141-2146
    CrossrefPubMedGoogle Scholar
  • 20 Woodworth BA, Prince A. Chiu AG et al. Spontaneous CSF leaks: a paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg 2008; 138: 715-720
    CrossrefPubMedGoogle Scholar
  • 21 Wall M. Idiopathic intracranial hypertension (pseudotumor cerebri). Curr Neurol Neurosci Rep 2008; 8: 87-93
    CrossrefPubMedGoogle Scholar
  • 22 Biousse V, Bruce BB, Newman NJ. Update on the pathophysiology and management of idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry 2012; 83: 488-494
    CrossrefPubMedGoogle Scholar
  • 23 Alexander NS, Chaaban MR, Riley KO, Woodworth BA. Treatment strategies for lateral sphenoid sinus recess cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg 2012; 138: 471-478
    CrossrefPubMedGoogle Scholar
  • 24 Cassano M, Felippu A. Endoscopic treatment of cerebrospinal fluid leaks with the use of lower turbinate grafts: a retrospective review of 125 cases. Rhinology 2009; 47: 362-368
    PubMedGoogle Scholar
  • 25 Lund VJ, Savy L, Lloyd G, Howard D. Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea. J Laryngol Otol 2000; 114: 988-992
    CrossrefPubMedGoogle Scholar
  • 26 Bachmann-Harildstad G. Diagnostic values of beta-2 transferrin and beta-trace protein as markers for cerebrospinal fluid fistula. Rhinology 2008; 46: 82-85
    PubMedGoogle Scholar
  • 27 Seth R, Rajasekaran K, Benninger MS, Batra PS. The utility of intrathecal fluorescein in cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 2010; 143: 626-632
    CrossrefPubMedGoogle Scholar
  • 28 Placantonakis DG, Tabaee A, Anand VK, Hiltzik D, Schwartz TH. Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery. Neurosurgery 2007; 61 (3, Suppl) 161-165 , discussion 165–166
    CrossrefPubMedGoogle Scholar
  • 29 Prickett KK, Wise SK, Delgaudio JM. Choice of graft material and postoperative healing in endoscopic repair of cerebrospinal fluid leak. Arch Otolaryngol Head Neck Surg 2011; 137: 457-461
    CrossrefPubMedGoogle Scholar
  • 30 Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012; 122: 452-459
    CrossrefPubMedGoogle Scholar
  • 31 Casiano RR, Jassir D. Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?. Otolaryngol Head Neck Surg 1999; 121: 745-750
    CrossrefPubMedGoogle Scholar
  • 32 Caballero N, Bhalla V, Stankiewicz JA, Welch KC. Effect of lumbar drain placement on recurrence of cerebrospinal rhinorrhea after endoscopic repair. International Forum of Allergy & Rhinology 2012
    PubMedGoogle Scholar
  • 33 Ramakrishnan VR, Suh JD, Chiu AG, Palmer JN. Reliability of preoperative assessment of cerebrospinal fluid pressure in the management of spontaneous cerebrospinal fluid leaks and encephaloceles. Int Forum Allergy Rhinol 2011; 1: 201-205
    CrossrefPubMedGoogle Scholar
  • 34 Eljamel MS. Antibiotic prophylaxis in unrepaired CSF fistulae. Br J Neurosurg 1993; 7: 501-505
    CrossrefPubMedGoogle Scholar
  • 35 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19: E8
    PubMedGoogle Scholar
  • 36 Carrau RL, Snyderman C, Janecka IP, Sekhar L, Sen C, D'Amico F. Antibiotic prophylaxis in cranial base surgery. Head Neck 1991; 13: 311-317
    CrossrefPubMedGoogle Scholar
  • 37 Choi D, Spann R. Traumatic cerebrospinal fluid leakage: risk factors and the use of prophylactic antibiotics. Br J Neurosurg 1996; 10: 571-575
    CrossrefPubMedGoogle Scholar
  • 38 Shikani AH. Use of antibiotics for expansion of the Merocel packing following endoscopic sinus surgery. Ear Nose Throat J 1996; 75: 524-526 , 528
    PubMedGoogle Scholar
  • 39 Fridley J, Foroozan R, Sherman V, Brandt ML, Yoshor D. Bariatric surgery for the treatment of idiopathic intracranial hypertension. J Neurosurg 2011; 114: 34-39
    CrossrefPubMedGoogle Scholar
  • 40 Stangherlin P, Ledeghen S, Scordidis V, Rubay R. Benign intracranial hypertension with recurrent spontaneous cerebrospinal fluid rhinorrhoea treated by laparoscopic gastric banding. Acta Chir Belg 2008; 108: 616-618
    PubMedGoogle Scholar
  • 41 Curry Jr WT, Butler WE, Barker II FG. Rapidly rising incidence of cerebrospinal fluid shunting procedures for idiopathic intracranial hypertension in the United States, 1988-2002. Neurosurgery 2005; 57: 97-108 , discussion 97–108
    CrossrefPubMedGoogle Scholar
  • 42 Ball AK, Howman A, Wheatley K , et al. A randomised controlled trial of treatment for idiopathic intracranial hypertension. J Neurol 2011; 258: 874-881
    CrossrefPubMedGoogle Scholar
  • 43 Kahle KT, Walcott BP, Staley KJ. Resolution of headache and papilledema in idiopathic intracranial hypertension associated with inhibition of Na+−K+−2Cl- cotransport. J Child Neurol 2011; 26: 205-208
    CrossrefPubMedGoogle Scholar
  • 44 Kumpe DA, Bennett JL, Seinfeld J, Pelak VS, Chawla A, Tierney M. Dural sinus stent placement for idiopathic intracranial hypertension. J Neurosurg 2012; 116: 538-548
    CrossrefPubMedGoogle Scholar